California is one of 10 states that have done the most to roll out provisions of the Affordable Care Act, according to a new Commonwealth Fund report. These states, including Colorado, Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, New York, Oregon and Vermont, have committed to implementing "the most significant aspects of health reform," the report states.

Most states, in fact, have played an active role in preparing for the health reform law, the report finds.

Texas, by contrast, is one of five states, including Alabama, Missouri, Oklahoma and Wyoming, with a hands-off approach to the health reform law, sometimes called Obamacare. These states aren't enforcing health insurance market reforms established under law, they rely entirely on the federal HealthCare.gov marketplace to enroll eligible consumers in health plans and they have declined to expand Medicaid, explained the report released Friday.

Other states fall somewhere in between.

"We tend to think about states as being fully opposed or fully supportive of health reform but the report shows that, in reality, there are many shades of gray that are worth recognizing," said study author Katie Keith, a former research professor at Georgetown University's Center on Health Insurance Reforms, now with the consulting firm Trimpa Group, L.L.C.

Take Virginia. It didn't expand Medicaid, nor did it establish its own marketplace, Keith pointed out. "But it is taking on a significant regulatory role in the marketplace by conducting plan management and [it] enacted legislation on all of the market reforms that we studied," she said.

Expanding access to affordable health care had been one of President Barack Obama's major campaign promises during the 2008 election cycle. After months of debate, negotiation and political wrangling, he signed the Patient Protection and Affordable Care Act in March 2010.

In June 2012, the U.S. Supreme Court upheld the law's individual mandate requiring that most Americans have health insurance or pay a penalty. But the court also allowed states to opt out of the law's Medicaid expansion without losing the federal funding they already received to administer Medicaid in the states.

The new report raises an important question: Will consumers experience health reform differently based on the decisions their states made?

Twenty-four states, by the Commonwealth Fund's count, have declined to expand Medicaid or remain undecided. Texas is one of them.

"We have 1 million people who are uninsured today who are too poor to get help through the marketplace and will have no access to affordable insurance," said Stacey Pogue, a senior policy analyst at the Center for Public Policy Priorities, an Austin-based advocacy group for moderate- and low-income Texans.

When people learn about the coverage gap, they are surprised, disappointed and angry, she said.

A new campaign from several community groups, "Texas Left Me Out," aims to put pressure on elected leaders to do something about it.

To better understand what states are doing to make health reform a reality, Keith and Georgetown's Kevin Lucia reviewed new actions taken by all 50 states and the District of Columbia between Jan. 1, 2010, and Nov. 1, 2013, to implement or enforce the Affordable Care Act's market reforms.

Thirty-two states and the District of Columbia passed new legislation or implemented regulations to carry out at least one of the Affordable Care Act's health insurance market reforms.

The law's market reforms protect patients by prohibiting health insurers from rejecting people based on preexisting health conditions, for example, and covering a minimum set of essential health benefits.

Seven states, including Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, Oregon and Vermont, have "fully embraced" the three major components of health reform by implementing market reforms, establishing a state-based marketplace and expanding Medicaid, the research team found.

Sixteen states and the District of Columbia have established their own health insurance marketplaces, or exchanges.

"It's very encouraging that nearly all states have taken some steps toward implementing or enforcing the Affordable Care Act," Sara Collins, the Commonwealth Fund's vice president for health insurance, said in a news release from the foundation.

"Already we can see the positive impact of their efforts as millions of people are gaining health insurance coverage through expanded Medicaid and the health insurance marketplaces," she pointed out.

"However," Collins added, "it is concerning that some states have taken only limited action, or none at all, since their low-income and uninsured residents in particular may not be able to fully benefit from the law."